Jagrutha Mahila Sanghatan, a Dalit women’s collective, formed in 1999-2000. AID has supported the group through projects, fair-trade marketing as well as solidarity to the Sanghatan in various phases. Along with AID-Bangalore volunteers Chetana, Karthik, Disha & Tamia, Ravi, Khiyali and I recently visited the women to hear their own reflections on their experiences and successes over the years, fighting oppression based on caste, gender and class, as well as ongoing challenges on all these fronts. Here are some photos from our visit with these grassroots partners.Continue reading →

Following are notes from a presentation I gave at the National Institute of Labour as part of a training program on Gender, Work, and Health. I presented on Women’s Health from a Women’s Rights Perspective, focussing on three themes, Birth, Breastfeeding and Food.

Before I continue to the three themes I presented, let me share some of my own apprehensions about speaking to both of these audiences.

My brief was to talk to the Ph D students about research methods and to the health officials about policy. Continue reading →

At a training program in Delhi, organized by the VV Giri National Labour Institute, I spoke on birth, breastfeeding and health from a women’s rights perspective. I gave the presentation to two groups – one comprised 36 PhD students from universities and institutes in various parts of India and the other comprised a similar number of health officials and physicians from developing countries outside India.

We sometimes talk about the inadequacies of the biomedical model of health and birth, insofar as it excludes social, psychological, environmental and spiritual factors. What we notice less often is the possibility that the biomedical model may itself depend on metaphors that are influenced by cultural stereotypes.

In the first part of my talk, I discussed gender stereotypes in the medical descriptions of women’s bodies and of reproduction. For this I relied on Emily Martin’s work The Woman in the Body and in particular “The Egg and the Sperm: How Science Has Constructed a Romance Based on Stereotypical Male-Female Roles.” (Signs, Vol. 16, No. 3 (Spring, 1991), pp. 485-501.

Drawing from several standard medical textbooks, Emily Martin shows that descriptions of women’s bodies reflect the values of industrial capitalism as well as gender bias and stereotype. Take away these values and substitute gender equality and women’s rights, and you would describe these processes quite differently.

I presented some of her examples and quoted from her article to explain each one. In summary these are:

Biological process

Standard Medical Textbooks

Why not

conception

journey of the sperm

interaction of egg and sperm

ovum

passive, fragile, dependent, waiting

connecting with sperm

sperm

active, strong, heroic, autonomous

connecting with egg

ovulation

overstock inventory

just-in-time maturation

spermatogenesis

amazing feat

excess

menstruation

failed production

indicator of fertility

menopause

factory shutdown

golden years

I continued to talk about how we had the choice to look at these processes in a way that grants women autonomy over their bodies and reproductive health, and this could help us to take a rights-based approach to women’s health. Just as I was about to move along to a discussion of women’s rights in birth, several hands flew up.

“The processes are described this way because that is the function of the reproductive organs,” one doctor said. I replied that we could look at the process differently if we did not assume that the objective of every woman and every menstrual cycle was to have children.

Why are you calling menopause “Golden years?” several men asked.

I answered that it signals a transition in life and that each phase of life could be appreciated on its own terms rather than regarding the woman’s body only through its child-bearing function. It is not to imply that earlier phases of life are less “golden” but simply to use a positive and respectful term.

“These ideas would be all right coming from a Western Perspective,” commented a physician from Sri Lanka. “But you being from our culture, should not be spreading these ideas. This kind of thought, if it spreads would be very dangerous,” he said. “It would cause a disruption in our society.” A physician from Afghanistan agreed with him and added, “In our culture motherhood is not a burden, it is a privilege.” One more health official from an African country added that menopause should not be called golden years and went on to explain that men could continue to reproduce for the whole of their lives.

I asked, “Can we hear from any of the women in the room?”

No one spoke up. The physician from Sri Lanka said, “I am speaking on behalf of the women.”

I was stunned that no one objected to such a statement. Nevertheless, I stayed on message and reiterated that a woman has the right to decide whether to have children and that having children was not the only, primary, or necessary purpose of a woman’s life and by extension, women’s health. To address women’s health from a women’s rights perspective, one must recognize the value of the body without limiting it to its capacity for childbearing. One must also respect women’s rights when addressing women’s reproductive and maternal health needs, including during pregnancy, labour, birth and beyond.

During the break several women approached me and said, “Your lecture is very interesting. Some of our colleagues are from very patriarchal backgrounds.” I said that they should speak up during the discussion. Later in the evening, I thought of I should have replied to those who cautioned against the social disruption that feminist ideas may cause. In order to make progress on women’s health issues, we must change our ideas and practices, and be prepared for the disruption that such change would cause.

Women’s options in childbirth are circumscribed by broader factors that determine their opportunities in life, whether and when to marry, to study, or work outside the home. The limiting factors include ideas about women’s bodies, of menstruation, fertility and reproductive cycles. Colluding with women’s sense of inferiority and powerlessness are government policies pushing women towards institutional childbirth and requiring women to report to the hospital at 9 months 3 days gestation. For women who do not go into labor at 9 months 3 days, this policy increases the likelihood of hospital birth and related interventions, including Cesarean birth. A generation is growing up that considers hospital birth and Cesarean birth to be “normal” and home birth or vaginal birth to be exceptional. In the process the tradition of midwifery is disappearing. This pattern reflects a broader global pattern in which traditional living practices such as natural birth, breastfeeding, sleepsharing, babywearing, and natural hygiene (also called elimination communication) are being disparaged and discontinued in societies where they have been in continuous practice up to the present generation, while being revived among the elite in the first world. These trends in turn impact attitudes towards learning, health, hygiene and natural resources in a way that creates a gap in the tradition so that the practices can no longer be handed down from elders but must be learned from books, classes or other media. Meanwhile government policies and profit-driven advertising promote institutional birth, bottle feeding, diapers, cribs and timetables of vaccination, discipline and education that are not oriented to optimal health, growth and learning of the child. Ironically, people believe that following these trends will help them climb the social and economic ladder, but in the larger picture we see that this helps to transfer from the poor to the rich, practices respecting health of mind, body and environment.

Re: maternal mortality in the first world

by LS Aravinda on Sat Nov 08, 2008 7:59 am

As with so many issues, we cannot do justice to the problem as it affects people in the third or fourth worlds, if we examine the problem only there. We must also recognize how this persists in the first world, affecting the affluent as well as those less so, and particularly prevalent among the third / fourth world pockets within the first world. In part this helps us understand reasons for maternal mortality that may not have to do with money or state-of-the art facilities. What are the factors related to attitudes, inequality, that contributed to this? How can cultures moving towards affluence and superior technology take care along the way to overcome or avoid the factors that allow maternal mortality to persist in the first world?

Maternal Morality rates in the US – ranked 20th according to CDC and 41st according to UN & WHO – are believed to be under-reported (only 21 US states record on the death certificates if the deceased was recently pregnant). Currently CDC reports maternal mortality rate to be 13 / 100,000 live births, up from 12 in 2003. It is also up from 8 in 1982, and once again higher than 10 , which was the rate in 1977. [A UN / WHO report (2007) places the US maternal mortality rate at 1 / 4800 or 21 / 100,000]. Maternal mortality in the African American community in the US is double, or more – one source reported 34 / 100,000 live births. Poor pre- and post-natal care, in-hospital neglect, denied right to information for patients, and low status of women, vulnerability of pregnancy / motherhood all play a role in this.

Midwife Ina May Gaskin has studied maternal mortality and complications in pregnancy and birth in the US and the social and political factors that cause these to persist and, in recent years, increase. She has raised awareness through the Safe Motherhood Quilt Project.

In “Masking Maternal Mortality, “(Mothering, March-April 2008, pp64-71), Ina May Gaskin asks the crucial question – WHY are we not talking about this serious issue in the United States? Why are we not alarmed that it persists? To her questions, I would add, what can developing countries like India learn from the persistence of maternal mortality in the US, as birth practices are rapidly changing – reducing risks in some spheres, while perhaps unkowingly increasing risks in others?

She writes about shocking cases of maternal death in the US. One case is that of Army soldier Tameka McFarquar who was transferred to New York from her tour of duty in South Korea after becoming pregnant. However, 10 days after being discharged from Samaritan Hospital in New York, she was found dead in her apartment, her newborn also dead from dehydration as there was no one else to notice that the mother was unable to care for her.

Just one follow-up visit would have detected the problem that cost her her life. Tragically, her chances of survival might have been higher had she not transferred to the US. South Korea has a lower maternal mortality rate than the US.

“noppulu rAkunDAnE tIsupOtunnAru.”
[they are taking them in even before contractions begin.]

“tommidi nellalu mUDu rOzulu avagAnE rammanTunnAru asupatriki”
[they are asking us to come in to the hospital by 9 months, 3 days]

Stirred by these anecdotes of rapid mass conversion from home birth to hospital birth in rural parts of Srikakulam district, I sought to talk in more detail with women about their birth experiences.

I met women in Tolapi and Appalagraharam villages, some of whom were receiving sOLLu pindi (ragi flour) in the AID India nutrition program. I said that child nutrition began before birth, even before pregnancy. A healthy woman would become a healthy mother and a healthy mother would be more likely to have a problem-free birth and be able to breastfeed easily. And so I asked them to share their usual dietary patterns, how these changed in pregancy and postpartum, and in this context asked them to share their birth experiences as well.

Those who had C sections, also known as “pedda operation [big operation]” said that they went to the hospital at the appointed time, often without any contractions at all. Generally people believed that once a Cesarean, subsequent births must be Cesarean and therefore the woman should not be kept at home waiting for contractions to begin but should just go to the hospital on the scheduled date. Other indicators for Cesarean, according to them were malpositioned baby or water breaking prior to onset of contractions. Apart from this since women were asked to come in at 9 months 3 days many went in prior to contractions anyway and for one reason or another had Cesareans. Many who went in after onset of contractions also reported that contractions slowed or stopped at the hospital and therefore they did have Cesareans.

In each village there were also home births and they described their birth experiences as well. I was mesmerised by the detail in which they could recall the progress of labor, indicating at what time contractions began, what they were doing at the time, whom they told (for some time they kept it to themselves so as not to interrupt what they were doing), right up to what time the baby was born.

One of the women who had a home birth reported that she did go into the hospital at 9 months 3 days as requested, and was asked to stay and wait for the baby to be born. However, her mother who went with her said that she was just fine and did not need to wait in the hospital and took her home. A few days later she delivered at home with only her mother to help her. Her mother was experienced in childbirth and was called by others as well. In another case the government nurse actually came home to deliver the baby for a woman.

There was also a case of a woman who delivered at home with a “mantrasani,” or traditional birth assistant, who lost the baby due to incompetent handling by the mantrasani. She reported that the mantrasani tried to pull the baby out by reaching in. The baby died. Another woman reported that because she had high BP the doctors told her that she could not deliver a breech baby and gave her injections to kill the baby. I asked why they did not do a Caserean delivery and she said that because of her high BP they could not do it. This happened in 1994. Since then she reports that she has fits and very poor memory.

After hearing all the stories I shared my birth experience as well. I also described what was happening during the “pains” which is the word used for contractions, and how this indicated that the body and baby were ready for the birth. 3 days past my due date my contractions began but occurred at 1 hour intervals. This continued for 7 days. I did not go to my midwife until the contractions came every 5 minutes. I told them that I was advised not to come in until contractions were 3-5 minutes apart, lasting 1 minute each and continuing at this rate for at least 1 hour. By waiting until this stage one could be relatively sure that the baby was ready to come and avoid unnecessary interventions. I emphasized that even if one had a Cesarean before one could possibly have a normal delivery next time. I asked them how long it took to reach the hospital and they said 30 minutes. This meant that they could definitely wait for labour to begin rather than going in advance “just to be safe.”

Some people asked how long you can wait – can you even wait till the 11th month?
Varalakshmi explained that we don’t always know the month that accurately, sometimes we may miss a period even before the pregnancy and think that we are farther along than we are. Also in case they are going by the lunar calendar, these months are 28 day months, which means that normal term is 10 full months. So entering the 11th month would be fairly common. Some people are counting in solar calendar months but then they should make sure they are not confusing the two.
We also talked about nutrition during pregnancy and postpartum. They reported that they were not getting the supplementary nutrition from the anganwadi as promised and for which their names were registered. We spoke with the anganwadi workers who reported that they were each responsible for 20-25 pregnant women but as their target was 8 women, they received supplies only for 8. Therefore they gave only to 8, sometimes by rotation so that they prengnant women would “adjust among themselves.”

Before coming to breastfeeding I also asked them about postpartum nutrition. I knew this would be an explosive topic. Postpartum dietary restrictions are quite tough on women. Many reported that they ate only one meal / day comprising dilute pappu (dal) or only charu with rice or chapati. Even those who raised a fuss (”goDava”) and ate 2 meals a day were very restricted in terms of what vegetables were allowed, and generally everyone reported feeling very weak and hungry during that time. Some took tonics from the doctor to help overcome this weakness and to produce milk. Some reported that they did not have milk and had to use cow’s milk or dabba (formula) milk. I emphasized that women should eat heartily during post partum without restricting any vegetable unless they personally had a problem with it, not because someone somewhere had a problem.

Some are even limited from eating their fill during pregnancy because they are afraid a big baby will be hard to deliver.

[I was in doubt about the whole peanut issue so I steered clear of it. Peanut was the only food I restricted during the first 2 years of breastfeeding, due to prevalence of peanut allergy in US. But the theory that allergies are likely to affect people in highly sanitary living conditions much more than those living with plenty of germs in the environment made me pause before casting aspersions on the peanut, which is a local crop, cheap and nutritious. ]

It seems that villagers think that rich people are healthier because they eat more expensive, i.e. packaged foods. So when they have a little spare money they try to buy packaged foods.

After learning more about their diets and diets of infants and children, we wanted to make a pamphlet on nutrition that would be locally relevant, written in colloquial language, focussing on the nutritional value of locally harvested food and how to incorporate more into the daily diet. We have made a rough draft and would appreicate help from anyone interested in nutrition and fluent in Telugu.